Urinary Incontinence in Women

Urinary incontinence is the leakage of urine due to loss of bladder control. The condition is common, impacting up to 50 percent of women.

While urinary incontinence occurs more often in older women, young woman may also be affected. The condition can severely impact a woman’s activities and quality of life.

Treatments are available to improve bladder control and restore a woman’s health and well-being.

Possible causes of urinary incontinence include:

• Urinary tract infections
• Urinary tract abnormalities, such as a fistula, an abnormal opening from the urinary tract into another part of the body 
• Medications
• Abnormal growths, such as polyps or bladder stones
• Poor muscle function, due to childbirth, neuromuscular disorders, or other conditions that affect the muscles that control the release of urine (urinary sphincter), which normally stay closed or contracted
• Neuromuscular problems that prevent signals from the brain and spinal cord from connecting properly with the bladder and urethra, the tube that carries urine from the body

The type of urinary incontinence a woman has will determine her symptoms and treatment options. The types of urinary incontinence include:  

• Stress urinary incontinence: Urine leakage that occurs when a woman is exercising, coughing, sneezing, laughing, lifting heavy objects, or doing other movements that put pressure on the bladder. In stress incontinence, the most common form of urinary incontinence, the muscles and nerves that normally keep the urethra closed don’t function properly, enabling urine to leak out. 
• Urgency urinary incontinence, or overactive bladder (OAB): A strong, urgent need to urinate, with leakage often occurring before reaching the bathroom, or the need to urinate frequently throughout the day and during the night. Urgency urinary incontinence occurs when the bladder muscles are “overactive,” contracting suddenly, often before the bladder is full, or when the brain signals to the bladder aren’t working properly. 
• Mixed incontinence: A combination of stress urinary incontinence and urgency urinary incontinence.
• Functional incontinence: Occurs in patients who cannot reach a restroom in time because of physical or medical conditions. 
• Overflow incontinence: Urine leakage that occurs in patients where the bladder doesn’t fully empty and then overfills, resulting in small amounts of urine leaking out.

Some factors that may increase your likelihood of developing stress incontinence include:

• Age
• Childbirth
• Obesity
• Illnesses that cause chronic coughing or sneezing
• Smoking, which can cause frequent coughing
• Diabetes, which can cause excess urine production and nerve damage
• Excess consumption of caffeine or alcohol

Stress urinary incontinence symptoms may include:

• Leakage when you cough, laugh or sneeze
• Leakage with physical activity such as running and jumping

Urgency urinary incontinence symptoms may include:

• Leakage associated with a strong urge to urinate, often without enough warning to get to the restroom in time 
• Leakage associated with a “trigger” such as the sound of running water, cold temperatures, or the anticipation of voiding

Diagnosis starts with a detailed medical history and a thorough discussion of your symptoms. During your visit, your urogynecologist may: 

• Ask questions about when and how often you experience incontinence.
• Conduct a physical examination, including a pelvic exam, to look for other conditions that may impact your bladder and cause your symptoms.
• Ask you to cough with a full bladder to see if you leak urine.
• Ask you to keep a bladder or voiding diary, where you record what you drink, how much, and how often. You would also measure and record how often and how much you urinate. 

Your urogynecologist may also recommend testing to help diagnose which type of urinary incontinence you have. Diagnostic testing may include:

• A urine analysis and culture to detect a urinary tract infection or blood in your urine
• Urodynamic testing to gain information about your bladder and urethra
• Cystoscopy to examine the inside of your bladder and urethra
• A 3D pelvic ultrasound to evaluate your pelvic floor muscles

Treatment varies based on the type of incontinence you have, your symptoms and treatment goals. Your urogynecologist will work with you to determine the best approach to relieve your symptoms. 

Lifestyle changes and pelvic physical therapy may be effective in treating both stress and urgency urinary incontinence, including:

• Lifestyle changes to reduce symptoms
  • Empty your bladder every 2-3 hours. 
  • Treat constipation to avoid straining with bowel movements.
  • Achieve and maintain a healthy weight.
  • Quit smoking. Smoking doubles the risk of developing a pelvic floor disorder.
  • Limit your intake of alcohol and caffeine.
• Pelvic floor physical therapy
  • A pelvic floor physical therapist can help rehabilitate your pelvic floor muscles and restore normal function. 
  • These specialists help you identify and isolate the pelvic floor muscles that need rehabilitation. Access to these muscles is typically through the vaginal opening.

When needed, additional treatment strategies include medications, nonsurgical options, and minimally invasive surgery. In many cases, a combination of these strategies may be used to alleviate your symptoms.

Other treatment options for stress incontinence focus on addressing the decreased function of the urethral and pelvic floor muscles.

• Pessary
  • A pessary is a removable device inserted into the vagina to keep the urethra closed, helping to control urine leakage. A pessary does not affect your ability to urinate normally.
  • Your urogynecologist will fit and insert the pessary. 
• Injectable urethra bulking agents
  • A bulking gel is injected into the walls of the urethra to help strengthen and bulk up the sides of the urethra so the tube narrows and closes tightly, decreasing or preventing leakage.
  • The benefits are immediate but the bulking effect may wear off over time, requiring another injection.
• Minimally invasive surgery - Surgery for urinary incontinence aims to compensate for the weakened sphincter muscle (urinary sphincter) and support muscles around the urethra that normally stay closed or contracted. These minimally invasive procedures have high rates of success. As with any surgery, there are risks involved. Talk with your urogynecologic surgeon about the treatment option best for you.
  • Midurethral sling
    • The most common and most studied stress incontinence procedure.
    • A synthetic mesh sling is inserted through a tiny incision in the front wall of the vagina and placed under the urethra. 
    • The sling helps lightly support and compress the urethra to prevent leakage when there is increased abdominal pressure (from laughing, running or jumping, for example).
    • Fast recovery time, with a return to activities within days.
  • Pubovaginal sling
    • A similar approach as with midurethral slings but pubovaginal slings are made using the patient’s connective tissue, known as “fascia.” The tissue is removed through a small incision in your abdomen.
    • This procedure may be recommended for women with prior surgery or certain risk factors.
    • The recovery time is longer and the potential risks are greater compared to midurethral slings.
  • Retropubic colposuspension
    • In this approach, stitches are used to support the urethra. This procedure is typically performed through an incision in your abdomen but can also be done laparoscopically or using robotic surgery. 

Other treatment strategies for urgency urinary incontinence (overactive bladder) focus on reducing the abnormal bladder contractions that can result in urine leakage. 

• Medications
  • Vaginal estrogen: A low-dose topical cream or vaginal tablet can improve the health and flexibility of the tissues in the urinary tract, relieving symptoms of urinary incontinence.
  • Anticholinergic medications: A daily dose of these oral medications can help prevent leaks by reducing involuntary bladder contractions. Talk with your urogynecologist about potential side effects, including constipation, dry mouth and the potential risk of cognitive changes and dementia with long-term use.
  • Beta-3 agonists: Taken orally once a day, medications such as mirabegron or vibegron can relax the bladder muscles, reducing leakage from unexpected contractions, with fewer side effects than anticholinergic medications.
• Minimally Invasive Procedures - If lifestyle changes and medications do not adequately improve symptoms of overactive bladder, there are several minimally invasive procedures that are low risk and effective at treating non-responsive or persistent symptoms.
  • Botox: Botox (Onabotulinum toxin A) injections in the wall of the bladder reduce urgency urinary incontinence by blocking the impulses being sent from the nerves to the bladder muscles, decreasing the contractions that cause urine leakage. The injections, which are administered during an office visit, typically need to be repeated every six to 12 months. There are few long-term side effects; talk with your urogynecologist to learn more. 
  • Sacral neuromodulation: Sacral neuromodulation, also known as sacral nerve stimulation, is a minimally invasive procedure that involves implanting a small device known as a neurostimulator (similar to a pacemaker) that sends mild electrical pulses to stimulate the sacral nerve, the nerve that influences bladder control muscles.

Healthy lifestyle habits may help prevent or ease the symptoms of stress incontinence, including:

• Exercise to strengthen your muscles 
• Maintain a healthy weight
• Eat plenty of fiber (to prevent constipation and the strain it places on pelvic floor muscles)
• Limit or avoid caffeinated and alcoholic beverages
• Stop smoking

Call (832) 826-7500 to make an appointment with a Baylor College of Medicine urogynecologist.